So, we have a few miniseries afoot here on Relentless Health Value right now, and one of them is "The Inches That Are All Around Us"—finding the hidden fees, the hidden friction for plans and members and clinics themselves a lot of times in those inches.
For a full transcript of this episode, click here.
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So, how does transparent pricing data fit in here? Well, you can use it to find inches. They are all around us. You can see it in this data. So, we talk about self-insured employers, plan sponsors, and their perspective on this price transparency data first in the conversation that follows. And then we get into the perspective of the provider organization or the clinic.
Let's take this from the top.
Plan sponsors such as self-insured employers or unions can gain three very interesting and maybe underappreciated insights from this price transparency data. Not limited, of course, to these three insights, but these were the three that Jerry DiMaso talked about; and I lasered in on them with very single-minded ambition.
Okay … so, here's the three insights of interest to plan sponsors. (1) Benchmarking against a plan sponsor's competitors. We often forget about this, that every self-insured employer is actually a company trying to sell something, probably with competitors.
You can search for your own plan or a competitor's plan using an EIN to compare rates, specific carve-outs, and identify if there are other companies in the same industry that are receiving better pricing.
Considering that paying for health benefits is often the second-biggest line item on many corporate balance sheets, I wonder how long it's going to take for some activist shareholder group to figure out that they can find evidence of avoidable overspending. Especially because of our number two insight here, which is (2) you can use this data to identify high-cost codes.
Plan sponsors can pinpoint specific billing codes where they are paying way too much. And right now (maybe you are, too) but I am thinking about the examples of infusions given in the recent episode with Ivana Krajcinovic, PhD (EP501) and that Brian Cotter talks about all the time. Also Nate Walker. Plans paying a million dollars too much for some infusion.
That would be a crazy thing for a corporate shareholder to figure out and bring up at some, I don't know, shareholder meeting or earnings call, right?
(3) Exposing the, I'm gonna call it, "discount shell game." This data allows plan sponsors to see through stuff like gross aggregated discounts. They can verify if a TPA's, I don't know, 90% discount is actually real savings.
Okay … so, what does one then do with these insights once found? Jerry DiMaso, again, my guest today in the conversation that follows, talks through these at some length; but here's the very top line.
First thing a plan sponsor can do is use this information to direct TPA negotiations. Plan sponsors can get their TPA to go back to providers and negotiate better rates. I did not know that.
Number two thing that a plan sponsor can do with this information: Implement service carve-outs and direct contracts. Employers can identify expensive outliers and then steer and tier and maybe direct contract with specialized providers or Centers of Excellence as a result of that knowledge.
As a second bit to this, not to be underestimated, this data allows for objective calculation of savings a lot of times from, you know, direct contracts or other initiatives so that plan sponsors don't have to rely on vendors to grade their own homework, as they say. Plan sponsors can start to do their own math.
And here's the last thing that we discuss in the episode that follows that a plan sponsor can do with this price data: Model alternative plan types. Right? You can analyze whether switching from a PPO to an HMO or some other alternative model would save money while actually maintaining access to the same providers that employees are already using.
Okay … so, now and in the conversation that follows, at this moment, we pivot to clinical organizations and how they can use this information. And by the way, although what we talk about next is of great interest to clinical organizations, lots of this is also still relevant to self-insured employers because, right, any ultimate purchaser does not want the independent practices to go outta business.
So, helping them make sure that they can stay in business is in everyone's best interest. I talk about this coming up with Patrick Nelli from Aligned Marketplace, and I talked about it with Dan Greenleaf from Duly in an episode.
Indie practices are just cheaper than consolidated health systems. If they go out of business, now all of the volume goes to consolidated health systems who now well and truly have a monopoly and all the glorious, unchecked pricing opportunities that go along with that. Anyway.
According to Jerry DiMaso, clinical organizations can use transparency data to level the playing field in a traditionally very asymmetric market when dealing with large carriers, large anybodies. And when I say asymmetric market, I mean many things, including asymmetric knowledge.
The specific ways that clinical organizations can leverage this data include (1) benchmarking and rate comparison. Providers can see the negotiated reimbursement rates for every procedure code for every medical practice, infusion center, and hospital in the country.
Sure, most know this one already, and there are also obvious pros and cons here; but this information is a plus for patients and members if it helps indie practices with strategic business planning forecasts, if it helps practices see when their internal costs are too high to trigger efficiency endeavors or maybe some other market driven activity. It is a plus if indie practices find codes that they are seriously under-reimbursed for. Bottom line, practices can make informed decisions and defend their value during contract negotiations.
(2) Identify new revenue channels. Smaller providers can discover contracts or carriers active in their geography that they were previously unaware of.
(3) Justifying rate increases via quality. Pairing their price data with their own superior outcomes and quality metrics. So, this data can be used as part of a larger strategic plan.
As I have mentioned at least three times already, today I am speaking with Jerry DiMaso, who is the CEO of Payerset. Payerset is a price transparency and healthcare pricing data aggregation company. They provide datasets and self-service analytics in their software, which several people have told me has a very elegant interface.
I also right now wanna take a moment to thank Payerset, who just came out of the blue one day last year and offered to help fund Relentless Health Value as a Series Underwriter.
They just wanted to help us stay on the air. And for reasons like this, my faith in humanity is restored every time I think about it. There are some amazing folks in this tribe of ours who really care and really try to do the right thing.
And with that, here is my conversation with Jerry DiMaso from Payerset.
This podcast is sponsored by Aventria Health Group with an assist from Payerset.
Also mentioned in this episode are Payerset; Ivana Krajcinovic, PhD; Brian Cotter; Nate Walker; Patrick Nelli; Aligned Marketplace; Dan Greenleaf; Duly Health and Care; Aventria Health Group; Eric Bricker, MD; Leo Spector, MD, MBA; Adam Stavisky; Ryan Wells; Health Here; Chris Deacon; Andrew Tsang; Pearly Chen; and Mark Cuban.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at payerset.com and by following Jerry on LinkedIn.
Jerry DiMaso is the co-founder and CEO of Payerset, where he leads the company's mission to democratize healthcare pricing. Under his direction, Payerset has built the infrastructure to parse, compress, and standardize trillions of payer-provider rates—giving healthcare teams reliable, decision-ready insights without the technical lift.
Jerry has spent his career at the intersection of data and technology, with experience spanning fintech, healthcare, and Pharma. He's led enterprise-wide data literacy initiatives, delivered high-impact analytics solutions for multiple Fortune 100 companies, and previously co-founded Knarr, one of the first truly collaborative analytics platforms.
His approach is simple: Technology should do the heavy lifting so people can make better, faster decisions.
00:00 Introduction to this episode.
00:50 How does transparent pricing data fit into the "inches all around us"?
03:13 A quick overview of what plan sponsors do with these price transparency insights.
05:52 The specific ways that clinical organizations can leverage price transparency data.
08:13 How price transparency infrastructure started and how it's grown to where we are now.
09:21 What are the insights that can be gleaned from the price transparency data available?
10:01 How price transparency data is a treasure trove for self-insured employers.
11:21 How employers can utilize this transparency data.
12:31 EP472 with Eric Bricker, MD.
14:48 How employers can help TPAs negotiate.
15:18 Why employers should be thinking about carving out services.
16:11 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky.
16:21 Why employers need to direct contract.
17:16 LinkedIn post by Chris Deacon.
17:38 A quick summary of advice for plan sponsors.
18:04 LinkedIn post by Andrew Tsang.
18:41 LinkedIn post by Pearly Chen.
19:32 How rates get set and how small providers can see this and benefit from it.
20:55 How small providers can use rate transparency to negotiate better rates.
22:18 EP489 with Dan Greenleaf.
25:46 Have prices increased due to price transparency?
29:25 Why price transparency makes it more important to eliminate lazy networks.
29:41 EP501 with Ivana Krajcinovic, PhD.
31:10 What is the transparency arms race, and what is happening because of it?
34:39 What Payerset does.
You can learn more at payerset.com and by following Jerry on LinkedIn.
@JerryDiMaso of @payerset discusses the #pricetransparency arms race on our #healthcarepodcast. #healthcare #podcast #financialhealth #commercialpayermarketplace #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation
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